Hostility, Anger, and Aggression

Transcription

1 1 Hostility, Anger, and Aggression Meaning and Interventions Michael Brunner, Ph.D., LP Clinical Director 2 Learning Objectives Identify two categories of aggression and the purposes served by hostility, anger, and aggression. List three factors, diagnoses, and other causes of hostility, anger, and aggression. Understand and describe the mutually destructive relationship between hostility, anger, and aggression and chemical use. Describe four targets for treatment of hostility, anger, and aggression and the timing of interventions to address the issue. Describe and be able to employ five treatment interventions for hostility, anger, and aggression. 3 Pre-test Question # 1 Impulsive aggression is associated with: a. High levels of emotional arousal b. Low levels of emotional arousal c. Anger or fear d. Both a & c e. Both b & c 1

2 4 What Distinguishes Hostility, Anger, and Aggression Hostility is an Attitude (way of thinking) Suggesting strong anger or opposition towards another person Anger is an Emotion Along with fear, sadness, and happiness is considered one of the primary emotions Aggression is a Behavior The physical display of both hostility and anger 5 Premeditated Aggression Planned behavior not typically associated with frustration or response to immediate threat Might not be associated with emotional arousal Clear goals in mind Also referred to as: Predatory Instrumental Proactive Siever, L. J. American Journal of Psychiatry 2008; 165 (4), Impulsive Aggression Characterized by high levels of emotional arousal Provoked by someone or something Anger or fear are associated with it Usually in response to a threat Also referred to as: Reactive Affective Hostile Siever, L. J. American Journal of Psychiatry 2008; 165 (4),

3 7 Hostility, Anger, and Impulsive Aggression They travel together they typically occur at the same time. Awareness of one can signal the emergence of another - for example, hostility can signal impending aggression. The root cause of these experiences hostility, anger, and impulsive aggression - is typically similar. 8 Post-test Question # 1 Impulsive aggression is associated with: a. High levels of emotional arousal b. Low levels of emotional arousal c. Anger or fear d. Both a & c e. Both b & c 9 The Role and Purpose of Hostility, Anger, and Aggression 3

4 10 Pre-test Question # 2 Preparing the body to respond to stress in the environment is the responsibility of which of the following? a. The sympathetic nervous system b. The parasympathetic nervous system c. The autonomic nervous system d. All of the above 11 What Purpose does Hostility, Anger, and Aggression Serve? Hostility, anger, and aggression has meaning: 1. It is a signal to others. It is COMMUNICATION. 12 So, if the purpose of Anger, Hostility, and Aggression is communication, what exactly is being communicated? 4

5 13 I m feeling backed into a corner. I don t feel safe. You don t want to be near me right now... Really. 14 But, hostility, anger, and aggression are not just a means of communication. They re also adaptive they serve an important purpose for the person. 15 Hostility, Anger, and Aggression are Primitive Survival Tools To the person expressing it, the message to oneself is clear: TAKE ACTION When functional, the goal is to: Get Something Protect Something 5

6 16 The Body s Response to Stress: Anger in Action Stress is the perception of a physical or psychological threat and the perception that one s responses are not adequate to deal with it. Within the body, there is a cascade of physiological events that prepares the person to respond to the stress. The stress response has also been referred to as the fight or flight response. 17 The Brain and the Body Responding to Stress 1. The cerebral cortex perceives the threat. 2. A signal is sent to the amygdala the brain center that activates the fight or flight response / the stress response system. 3. The brain prepares the body for response to the threat via central (brain-related) and peripheral (body-related) responses. 4. Once the threat is dealt with, the stress-response system is turned off. 18 Peripheral Nervous System Consists of: Sensory neurons running from stimulus receptors that inform the CNS of the stimuli. Motor neurons running from the CNS to the muscles and glands - called effectors - that take action. 6

7 19 The Stress Response: The Autonomic Nervous System 20 If the fight or flight response is an adaptive response to stress and hostility, anger, and aggression are revealed in this response, then these experiences can be regarded as adaptive sometimes. So, when is it that hostility, anger, and/or aggression pathological, unhealthy, or maladaptive? 21 When is Premeditated Aggression Pathological? Almost always... There is a manipulative quality to it Sometimes pleasure is derived from this type of aggression There may be little to no arousal in the regions of the brain that would signal an emotional reaction to the aggression. 7

8 22 When is Impulsive Aggression, Anger, or Hostility Pathological? When it is exaggerated in relation to the emotional provocation. When it is the predominant response to stress. It feels or is beyond one s control. It causes problems or dissatisfaction in one s life. 23 Section 1 Summary - Hostility, Anger, and Aggression: 1. Carries meaning. 2. Is communication. To others it says, Pay attention! 3. Is a message to oneself. It announces, Take action! 4. Serves to propel the person to either get something or protect something. 5. Is integrally related to the adaptive stress / fight or flight response. 6. Though adaptive, it can cause significant problems in people s lives when gone awry. Post-test Question # 2 Preparing the body to respond to stress in the environment is the responsibility of which of the following? a. The sympathetic nervous system b. The parasympathetic nervous system c. The autonomic nervous system d. All of the above 24 8

9 25 Hostility, Anger, and Aggression in Chemical Dependence treatment Data from residents at Fountain Centers programs in Albert Lea, Rochester, Mankato, Faribault, Owatonna, Fairmont, Waseca, and Jackson, MN 26 Fountain Centers 27 Questions Used to Assess Hostility, Anger, and Aggression Global Appraisal of Individual Needs Short Screener (GAIN-SS) Four Questions used to assess hostility, anger, and aggression: 1. When was the last time that you did the following things two or more times? a) Were a bully or threatened other people? b) Started physical fights with other people? 2. When was the last time that you a) Had a disagreement in which you pushed, grabbed, or shoved someone? b) Purposely damaged or destroyed property that did not belong to you? Answered: 3 = Past month; 2 = 2 to 12 months ago; 1 = 1+ years ago; 0 = Never 9

10 28 Fountain Centers Clients Purposely damaged or destroyed property that did not belong to you? Past month or 2-12 months Men Women Adolescent Males Adolescent Females N % 13% 47% 33% 1+ Year Ago 30% 19% 17% 33% Never 55% 68% 37% 33% 29 Fountain Centers Clients Purposely damaged or destroyed property that did not belong to you? Past month or 2-12 months Men Women Adolescent Males Adolescent Females N % 0% 13% 0% 47% 33% 1+ Year Ago 30% 38% 19% 21% 17% 33% Never 55% 62% 68% 79% 37% 33% 30 Fountain Centers Clients Have you bullied or threatened other people? Past month or 2-12 months Men Women Adolescent Males Adolescent Females N % 27% 30% 50% 1+ Year Ago 26% 21% 27% 8% Never 61% 52% 43% 42% National average for bullying for adolescents in one study estimated to be 13% (Nansel et al JAMA (2001) 285 (19), ). 10

11 31 Fountain Centers Clients Have you bullied or threatened other people? Past month or 2-12 months Men Women Adolescent Males Adolescent Females N % 0% 27% 0% 30% 50% 1+ Year Ago 26% 25% 21% 32% 27% 8% Never 61% 75% 52% 68% 43% 42% 32 Fountain Centers Clients Started physical fights with other people? Past month or 2-12 months Men Women Adolescent Males Adolescent Females N % 17% 50% 50% 1+ Year Ago 25% 24% 27% 17% Never 64% 59% 23% 33% One study found that 40.7% of adolescent males and 24.4% adolescent females were in a physical fight in the last year. (MMWR () 61(4) 7). The rate of simple assault as measured by the BJS for those age 12 and older in 2011 was 1.5% (Bureau of Justice Statistics, National Crime Victimization Survey, 2002, 2010, and 2011; Fountain Centers Clients Started physical fights with other people? Past month or 2-12 months Men Women Adolescent Males Adolescent Females N % 0% 17% 0% 50% 50% 1+ Year Ago 25% 13% 24% 11% 27% 17% Never 64% 87% 59% 89% 23% 33% 11

12 34 Fountain Centers Clients Had a disagreement in which you pushed shoved, or grabbed someone? Past month or 2-12 months Men Women Adolescent Males Adolescent Females N % 35% 77% 83% 1+ Year Ago 42% 24% 10% 8% Never 35% 41% 13% 8% 35 Fountain Centers Clients Had a disagreement in which you pushed shoved, or grabbed someone? Past month or 2-12 months Men Women Adolescent Males Adolescent Females N % 0% 35% 7% 77% 83% 1+ Year Ago 42% 38% 24% 43% 10% 8% Never 35% 62% 41% 50% 13% 8% 36 Factors, Diagnoses, and Other Common Issues Associated with Hostility, Anger, and Aggression 12

13 37 Pre-test Question # 3 In the study by Caspi et al (2002) which of the following was found to confer the greatest risk to future aggression and violence? a. Childhood abuse b. Genes c. The interaction between genes and the environment d. Having a hostile temperament as a child Predictors of Aggression/Violence Static Unalterable Factors Previous history of violence Male Young adult Lower intelligence History of head injury History of military service Weapons training Past diagnosis of major mental illness Anderson, Western Innovations in Clinical Neuroscience (2011) 8(3): 34-9; Bobes et al., Acta Psychiatry Scananavia (2009) 119, ; Fazel et al., Journal of Clinical Psychiatry (2009) 70(3), 362-9; Swanson et al. Hospital Community Psychiatry (1990) 41(7), (Slide and references: NEI Congress) Dynamic Can be changed to improve outcome Substance use Current symptoms of major mental illness Persecutory delusions Command hallucinations Depression Hopelessness Suicidality Treatment Nonadherence Impulsivity Access to weapons 13

14 40 Other Factors that Influence Anger and Aggression Low self-esteem* Under-socialized Lacking skills to negotiate situations that may provoke conflict Situational Factors Pain and discomfort Frustration being blocked from achieving a goal Problems with or disordered sleep *Donenllan, Psychological Science (2005) 16(4), Genes and Propensity to Aggression In recent years, certain genes have been found to be associated with a propensity to aggression and violence in certain situations. For example, a variant of the MAO gene, one that controls the breakdown of neurotransmitters, is associated with increased aggression and violence. * This gene was dubbed the warrior gene. Multiple genes in interaction with other genes, not single genes, are being found to create a heightened risk for complex behaviors such as aggression. *Brunner et al Science (1993) 262, Environmental Influences on Aggression It has long been known that childhood maltreatment is a universal risk factor for antisocial behavior. Boys exposed to erratic, coercive, and punitive parenting are at risk for conduct disorder, antisocial personality symptoms, and becoming violent offenders. The earlier the maltreatment occurs, the greater the risk for these later problems. However, there are large differences between children who are exposed to maltreatment not all go on to become delinquents or adult criminals. Widom, Science (1989) 244, 160; Rutter et al, Antisocial Behavior by Young People (1998), Cambridge U. Press; Kelley et al, Dev. Psychopathology (2001) 13,

15 43 Genes and Environment and Aggression Genes interact with the environment. For example, in 2002 a study found that men with a copy of the warrior gene only exhibited violence if they experienced maltreatment as children. Being raised in a caring environment neutralized the negative effect of the gene on later aggression and violence. This gene-environment interaction has been found in other studies as well involving this gene since Caspi et al., Science, (2002) 297: Mild Stress What May Happen to At-Risk Genes Over Time in a Stressful Environment Time 1 Time 2 Time 3 (etc) Outcome I cause trouble. Moderate to High Stress 45 Chronic Stress is the Culprit Individuals who experience chronic stress are at greatest risk for problems later in life. Experiencing this stress as a child creates even greater risks as it results in structural and functional changes to the developing brain. If, on top of this, you are born with compromised genes you are at greatest risk for impairment, both as a child and as an adult. 15

16 46 What May Happen to At-Risk Genes Over Time in a Nurturing Environment Time 1 Time 2 Time 3 (etc) Outcome 47 Do those in Fountain Centers with More Recent Aggression have More Adverse Childhood Experiences* (ACEs)? ACEs are a series of 10 questions assessing the number of negative experiences in childhood that an individual reports. An individual can achieve a score from 0 to 10, with lower scores representing fewer ACEs. The prevalence Each Yes answer earns a score of 1. the ACE study Higher scores are associated with a host of adverse population is as follows: outcomes in adulthood including physical and 0 = 33%, 1 = 26%, mental health and social problems. 2 = 16%, of ACE Scores in 3 = 10%, >4 = 15%. *Felitti et al, Am J Prev Med (1998). 14(4), ACEs Questions While you were growing up, during your first 18 years of life: 1. Did a parent or other adult in the household often or very often Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt? 2. Did a parent or other adult in the household often or very often Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured? 3. Did an adult or person at least 5 years older than you ever Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you? 4. Did you often or very often feel that No one in your family loved you or thought you were important or special? or Your family didn t look out for each other, feel close to each other, or support each other? 16

17 49 ACEs Questions (cont d) 5. Did you often or very often feel that You didn t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it? 6. Were your parents ever separated or divorced? 7. Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit at least a few minutes or threatened with a gun or knife? 8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs? 9. Was a household member depressed or mentally ill, or did a household member attempt suicide? 10. Did a household member go to prison? 50 Do females who report more recent aggression* also report more adverse childhood experiences (ACEs)? Were a bully or threatened other people Purposely damaged or destroyed property that did not belong to you r=.34 t * Selected the GAIN-SS questions with the highest correlation to the ACEs score. t Correlations in this range are generally regarded as moderate to strong. Past month or 2-12 months 1+ Year Ago or Never Bully or Threatened Others r =.43 t Destroyed Property 5.7 (n = 29) 5.9 (n = 14) 3.2 (n = 62) 3.6 (n = 75) The prevalence of ACE Scores in the ACE study population is as follows: 0 = 33%, 1 = 26%, 2 = 16%, 3 = 10%, >4 = 15%. Do males who report more recent aggression* also report more adverse childhood experiences (ACEs)? Were a bully or threatened other people r =.36 Purposely damaged or destroyed property that did not belong to you r =.36 t Again, correlations in this range are generally regarded as moderate to strong. Past month or 2-12 months 1+ Year Ago or Never Bully or Threatened Others Destroyed Property 4.3 (n = 27) 3.7 (n = 32) 2.0 (n = 144) 2.1 (n = 136) 51 The prevalence of ACE Scores in the ACE study population is as follows: 0 = 33%, 1 = 26%, 2 = 16%, 3 = 10%, >4 = 15%. * Selected the GAIN-SS questions with the highest correlation to the ACEs score. 17

18 52 Diagnostic and Statistical Manual Fourth Edition Text Revision (DSM-IV-TR) Possible causes of aggression, anger, and hostility 53 Cluster B Personality Disorders # 1 Antisocial - A pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence (often diagnosed as conduct disorder) and continues into adulthood Tend to be callous and unconcerned for the feelings of others. Tend to have a very low tolerance for frustration and a low threshold for discharge of aggression. Often maintain persistent irritability. 54 Cluster B Personality Disorders # 2 Borderline - also known as emotionally unstable personality disorder, is a psychological condition marked by a prolonged disturbance of personality function, characterized by depth and variability of moods. Tend to think in black-and-white terms, often manifests itself in idealization and devaluation episodes and chaotic and unstable interpersonal relationships, self-image, identity, and behavior, as well as a disturbance in the one's sense of self. React with anger when experiencing perceived rejection, being alone, or perceived failure. Rapid swings from anger to anxiety to depression. Anger is inappropriate. Has difficulty controlling anger. 18

19 55 Cluster B Personality Disorders # 3 Narcissistic - a personality disorder in which the individual is described as being excessively preoccupied with issues of personal adequacy, power, prestige, and vanity. Tend to be controlling, blaming, selfabsorbed, intolerant of others views, of others' needs, and of the effects of their behavior on others. unaware React with anger and rage when experiencing criticism, real or imagined, and when they feel their sense of self is threatened. 56 Impulse Control Disorders Intermittent Explosive Disorder is a behavioral disorder characterized by extreme expressions of anger, often to the point of violence, that are disproportionate to the situation at hand. Impulsive aggression is unpremeditated and is defined by a disproportionate reaction to any provocation, real or perceived. 57 Other Causes of Hostility, Anger, and Aggression # 1 Brain Injury Cognitive Deficits Social Skills Deficits Thought Disorders Especially delusions 19

20 58 Other Causes of Hostility, Anger, and Aggression # 2 Medical Conditions Any disease condition that taxes the physical status of the individual Alcohol or other drug use or withdrawal Chronic use of drugs of abuse can permanently alter the structure and function of the brain, including predisposing a person to precipitous anger. 59 Susceptibility to Aggression and Psychiatric Diagnosis Co-Occurring Problem Type of Aggression Susceptibility to Aggression Psychosis and cognitive impairment Anxiety and trauma Emotional sensitivity and dysregulation Psychopathy Deviant Behaviors Reactive and impulsive; with trauma triggered by cues associated with trauma Impulsive or reactive; e.g., borderline PD Premeditated; e.g., Antisocial PD Siever, L. J. American Journal of Psychiatry 2008; 165 (4), Section 2 Summary Static factors, such as age and gender, and dynamic factors, such as mental illness and substance use, can increase the prediction of hostility, anger and aggression. There are several common factors associated with hostility, anger, and aggression: 1. Genes and the interaction between genes and the environment. 2. Personality disorders, particularly Cluster B. 3. Impulse control disorders those with no known cause. 4. Brain injuries, cognitive and social skills deficits, thought disorders, medical conditions, and drug use and withdrawal. 20

21 61 Post-test Question # 3 In the study by Caspi et al (2002) which of the following was found to confer the greatest risk to future aggression and violence? a. Childhood abuse b. Genes c. The interaction between genes and the environment d. Having a hostile temperament as a child 62 The Association Between Chemical Use and Hostility, Anger, and Aggression 63 Pre-test Question # 4 What would be the best treatment intervention for someone whose anger is associated with anxiety? a. Seeking Safety / milieu-based program emphasizing predictability b. Relaxation strategies such as meditation c. Skills training such as DBT d. Exercise and sleep hygiene 21

22 64 The Association with Chemical Use Chemical Use Hostility, Anger, & Aggression May increase or decrease with substance use 65 Intoxication, Aggression, and Substance Use Hostility, Anger, and Aggression Hypotheses Chemical use or withdrawal is the cause A co-occurring disorder is the cause Use substances to control Outcome as substances clear the body 66 Co-occurring Disorders as Medicating Problems Clearly, many drug users consume alcohol and other drugs to make unpleasant emotions, such as anger, and life more tolerable. This solution is at best a short-term attempt to cope and not getting at the underlying problems. More typically, chemical use worsens the very problems the user is trying to sooth with chemicals by: Preventing the development of adaptive coping strategies. Making the person more vulnerable to adverse consequences, thus increasing anger, despair, and feelings of lack of control in one s life. Damaging brain circuits required for management of anger and impulses. 22

23 67 Drug User s Faulty Beliefs and Hostility, Anger, and Aggression Alcohol and other drugs: Calm me down Belief Help me manage my anger and aggression Makes me more pleasant to be around Takes the edge off Helps me tolerate unpleasant people and situations Reality Decreases inhibitions; Increases suspiciousness Typically impairs judgment Alters personality, often in unpleasant ways Often increases impulsivity Makes user more unpredictable and unpleasant 68 How to Intervene During CD Treatment Co-Occurring Problem Responsible for Hostility, Anger, or Aggression Psychosis or delusions Interventions Stabilize psychotic/delusional thinking Cognitive impairment Anxiety Trauma Emotional sensitivity and dysregulation (e.g., BPD) Psychopathy (e.g., APD) Concrete instructions and interventions Relaxation training; mindfulness; and cognitive behavioral strategies Seeking Safety; treatment milieu emphasizing safety, support, and dignity Skills training, for example Dialectic Behavioral Therapy-type interventions Highly behavioral / extremely structured milieu 69 Section 3 Summary Alcohol and other drug use: Reinforces and is reinforced by problems of hostility, anger, and aggression. Creates the very problems users hope to ameliorate with chemical use. Goes hand-in-hand with faulty beliefs about the role of substances in one s life. Addressing anger, hostility, and aggression requires a clear understanding of the causes. 23

24 70 Post-test Question # 4 What would be the best treatment intervention for someone whose anger is associated with anxiety? a. Seeking Safety / milieu-based program emphasizing predictability b. Relaxation strategies such as meditation c. Skills training such as DBT d. Exercise and sleep hygiene 71 Case Example 72 Interventions 24

25 73 Pre-test Question # 5 For someone who is acutely agitated, the type of intervention that is most likely to be successful will focus on: a. Top-down, prefrontal processing b. Bottom-up, amygdala-directed strategies c. Interventions with specific, clear, concise directions d. Removing triggers from the situation 74 Top-Down Regulation of Brain Functioning During Calm Times The Prefrontal Cortex regulates thought and action. The PFC is often referred to as the brakes, slowing down impulse-driven actions. PFC Prefrontal Cortex DLPFC Dorsolateral PFC DMPFC Dorsomedial PFC ripfc Right Inferior PFC VMPFC Ventromedial PFC NA Norepinephrine DA - Dopamine Notice the many direct and indirect connections to other brain regions. Arnsten, A. F. T. (2009) Nature Reviews Neuroscience 75 Bottom-Up Regulation of Brain Functioning During Stressful Times The Amygdala regulates fear and reward processing and emotion. Drives, impulses, and instinctual responding is regarded as originating here. When the amygdala fires up, prefrontal processing shuts down. Arnsten, A. F. T. (2009) Nature Reviews Neuroscience 25

26 76 Therapeutic Interventions Different targets: The person The person s emotions The symptoms Self-awareness Person Symptoms Emotions Self- Awareness 77 Timing and Therapeutic Interventions Person Intervening with a person who is at risk for hostility, anger expression, and aggression prior to their display of the associated behavior and emotions is... PREVENTION

27 79 Prevention # 1 Know your client Be aware of the factors associated with the anger. The causes and diagnoses provide a guide for treatment interventions. Inoculation Address anger as an issue from the outset. How is this issue likely to play out in treatment? How has this caused you problems in the past? When I/we see this issue in your treatment, what would be the most helpful way to address it with you? 80 Prevention # 2: Top-down or Bottom Up? Focus on the Relationship Genuineness Empathy and understanding Show Interest Listening Inquiring Demonstrate Positive Regard 81 Prevention # 3: Top-down or Bottom Up? Include strategies for management of hostility, anger, and aggression in the treatment plan. Give the client homework assignments to practice anger management strategies. Treatment Interventions: Relaxation training / meditative practices Cognitive behavioral strategies, especially focused on thinking errors and relapse prevention Skills training, especially role playing around issues involving intense emotional exchanges, communication, and assertiveness Involvement in a healing community, e.g., AA/NA, faith group 27

28 82 Timing and Therapeutic Interventions Person Emotions Addressing signs of distress or troubled emotions prior to them becoming full blown expressions of hostility, anger, or aggression is... Early Intervention Early Intervention: Top-down or Bottom Up? Noticing and Acknowledging Attending and Listening Suggesting and Directing Separate from the provocative stimuli Use relaxation Practice thought stopping or other cognitive strategies 28

29 85 Timing and Therapeutic Interventions Person Emotions Symptoms 86 Timing and Therapeutic Interventions Intervening with a client after hostility, anger, or aggression has been displayed is... De-escalation Symptoms 87 When Anger or Aggression are Being Expressed, Remember... Rational, top-down, prefrontal processing of information is absent. Therefore, talking rationally is not an option. Emotional, bottom-up, amygdala-driven reacting predominates. Therefore, interventions aimed at calming the person are most likely to be successful. 29

30 88 De-escalation: Top-down or Bottom Up? Containing Separate from others and potential hazards. Redirecting Clear, concise messages about what you need the individual to do. Repeat the message. Calming Help the individual employ self-calming strategies. 89 Timing and Therapeutic Interventions Person Emotions Symptoms Self- Awareness 90 Timing and Therapeutic Interventions After de-escalating, the opportunity exists for new learning or... Self- Awareness Consolidation 30

31 91 92 Consolidation: Top-down or Bottom Up? Anger Process and learn from the experience Identify triggers for anger Develop new strategies for anger management Practice new skills Rinse, wash, repeat 93 Section 4 Summary Interventions to address hostility, anger, and aggression vary depending on one s target and timing. Target Person Emotion Symptom Self-Awareness Stage Prevention Early Intervention De-escalation Consolidation 31

32 94 Post-test Question # 5 For someone who is acutely agitated, the type of intervention that is most likely to be successful will focus on: a. Top-down, prefrontal processing b. Bottom-up, amygdala-directed strategies c. Interventions with specific, clear, concise directions d. Removing triggers from the situation 95 Summary Anger, Hostility, and Aggression It has meaning. It is useful to understand what a person s anger is communicating. There are multiple causes of anger and factors associated with it. Knowing the causes is like having the early stages of trip mapped out. Chemical use worsens problems of anger. Interventions can be matched to the stage at which anger is observed to be at issue